Microsoft word - medical_form_2009.doc

MEDICAL INFORMATION, PERMISSION AND RELEASE FORM
Health Problems we should know about:(Allergic to Bee Stings, Asthma, Diabetes, Recent Illnesses or Injuries [anything you have seen a doctor for in the past 6 months], etc.): Daily/Regular or “as needed” Medications (ex: Allergy, acne medication, etc.):
A WBOP chaperone will have the following over-the-counter medications available to treat common conditions: Tylenol or Advil (pain/headaches) Midol (females only - cramps) Benadryl (allergies) Sudafed (congestion) Dramamine (motion sickness) Tums or Pepto-Bismol (upset stomach) Imodium (diarrhea) My student may be given these medications if needed: ____ yes ____ no

All information will be held in the strictest confidence and will be used on an “as needed” basis only. *** PLEASE FILL OUT BOTH SIDES OF THIS FORM AND ATTACH COPY OF INSURANCE CARD *** Medical History Permission and Release Form
Name:________________________________________________ Age:_____________________
Address:______________________________________________ Zip:______________________
Incase of an emergency, notify:_____________________________Phone:___________________
Family Physician: ________________________________________ Phone:__________________
Family Insurance Co._____________________________________ Policy #__________________
Insurance Co Address: _____________________________________________________________
Other:___________________________________________________________________________
Asthma___ Sinusitis___ Bronchitis___ Kidney___
Food____________________________ Insect bites/strings____________________
Penicillin or other drug (name)____________________________________________
Poison Sumac, Oak or Ivy_______________________________________________
Other________________________________________________________________
Previous operations or serious illnesses__________________________________________________
medications______________________________________________________________
Special diet (name)__________________________________________________________________
Chickenpox_____Measles_____Mumps____Whooping Cough_____
Any medical needs which your child has, of which adult supervisors should be aware:
___________________________________________________________________________________
My permission is granted for school supervisors to obtain necessary medical attention in case of sickness or injury of my student. I release and waive, and further agree to indemnify, hold harmless or reimburse the Cobb County School District, the Board of Education, its successors and assigns, its members, agents, employees, and representative thereof, as well as trip supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the student, or any other person, firm or corporation my have or claim to have, known or unknown, directly or indirectly, from any losses, damages or injuries arising out of, during or in connection with the student's participation in the trip or the rendering of emergency medical procedures or treatment, if any.
DATED this__________of___________, 20____
_______________________________________________ NOTARY _______________________

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